According to the US2010 Project, immigrants from Latin America, Asia, and elsewhere have expanded the population of minority residents beyond African Americans, a trend that experts say will eventually lead to as many "minority" as "non-minority" residents, if it continues.

As of 2010, western, southern and coastal metropolitan areas continue to be the most diverse, with California's Vallejo-Fairfield claiming the top spot.

In addition to location and how evenly a city's population was distributed across racial groups -- a perfectly diverse place would have a population with exactly 20 percent of each category and a total score of 100 -- the community characteristics researchers correlated with diversity were: large total and foreign-born populations; high rental occupancy, as a community needs a supply of rental housing to accommodate newcomers; a range of occupational options, including entry-level jobs; and a low minority-to-white income ratio.

Check out this article to see the most and least diverse cities in the U.S.

Student at the UCLA School of Nursing start their nursing career with a high tech boost. As part of their ceremony to receive their white coats, this year they were also give iPod Touch devices preloaded with Medication and Diagnosis guides as well as a Spanish language dictionary and translation assistance. UCLA is determined to offer new grad nurses that are ready for "High Touch" care but within a "High Tech" environment.

The important things to bridge the differences in the professional nursing practice in the United States are:

1. Develop critical thinking skills. Always ask how, what, when, where, who, and what-if questions. Seek to understand the need for what is not understood. It creates deeper and more meaningful learning when we ask questions and search for answers. It also expands knowledge and leads to future change with less frustration.

Identify the difference, seek to understand and to assess the situation or question at hand.

Observe the evidence of practice.

Develop a self-improvement list for ourselves.

Analyze content, including the policies and procedures of our facilities.

Interpret, verify and explain findings to our way of understanding.

Evaluate for relevant criteria to make a good judgment.

Apply new ways of thinking and immerse into the new knowledge as our own, using it in new clinical settings.

Create an action plan. Make a strong personal commitment to act differently in the nursing practice. Commit to doing things in new ways and not slide back into the old way of doing things. Adjust our behaviors again as needed. Apply new action plans to adopt better nursing practices for ourselves.

2. Be true to ourselves. Stay strong, positive, and use positive energy everyday. Do not fall into the trap of negativity. Keep eyes open, mind clear, and refuse to go into a negative pit. There is no room for negativity.

Build our brand. One simple example to think about branding is to look at a change shift. When a nurse comes in tardy; we hear some people say, “She is never late; she is always on time. Hope she is okay.” But we also frequently hear others say “She is always late. We don’t have to wait for her, let’s get started.” Ask yourself: Who do we want to be? It takes a plan and determination to come to work on time on a consistent basis. Our brand is built by what we do day in and day out. We want to make a conscious decision to align ourselves with true greatness.

Practice positive self-talk to make self-affirmation a daily habit. Think about how many people are able to excel in another land. We use a different language all day at work, and we work in a people profession – around people, and taking care of people. We are a different breed. We are doing great!

Excel in our strengths. When we posses excellent skills, use them. Peripheral IV (PIV) insertion it is a great time-saving skill. Help out where you are most skilled. Hold onto what is good, but assess if there’s a new, better way. Let’s raise the bar for ourselves.

3. Limit negativity.

Take pride in our bilingual skills. Being bilingual is a gift. It is not a negative attribute. Speaking bilingual gives us the opportunity to explore understanding of words or phrases that are foreign to us. Volunteer to be an interpreter for patients who speak our native language whenever you can. Never use our cultural background as an excuse for not being an effective communicator. We need to continue to improve speaking English. We can learn to communicate more effectively every day. We can write down our successful sentences and deposit them in a basket. Pick them up to read them again once a while.

Create ways to help deal with negative people around us. When we distance ourselves from the negativity or person, people may misinterpret our behavior into a negative behavior. Our actions may be interpreted as anti-social. Mingle, but avoid joining in negative talk. It unrealistic for us to expect to never encounter rejection or discrimination in the workplace. That is purely naïve. Rejections and discriminations are likely to happen to us. They happen for many reasons beside cultural differences. We do not appreciate experiencing rejection and discriminations at work. How one deals with the experience is a big lesson to learn. Let’s ask ourselves: What are we going to do if we encounter these things? What can we learn from this encounter? Do we want to tolerate it? How much can we tolerate it? What is our personal limitation? What can we do to change? How much time do we want to spend on unhappy events? Is this experience going to affect us one year from now? Five years from now? Ten years from now? At different times, we do different things. Therefore, a flexible plan will be very helpful. It is easier to deal with situations if we already have a thoughtful plan. At the very least, we have a lawful process to resolve discrimination. Always seek to understand. Explore how things can be improved.

We also need to find our own ways to deal with whatever we encounter. I will share my own terrible experience. The incident happened just before I was going to a beautiful wedding. I was determined not let the terrible experience ruin a good time at the wedding so I compartmentalized my horrible experience. I went to my secret “P” pocket (I have many words which start with “P” in my mind that I can use to boost my positive energy when I needed). I pulled two “P” (Personally and Permanent) words out. I kept telling myself over and over “Don’t take it personally.” “The problem is hers.” “I did what I need to do for my job.” I also told myself again and again that “Nothing is permanent. This shall pass.” I repeated these sentences to myself until I was at peace. That night, I was able to enjoy the wedding. I could think about how to deal with my bad experience after the wedding.

4. Plan to bridge the differences in our nursing practices in many steps.

Initial self-assessment and learning to fill the missing pieces of the puzzle for ourselves.

Find a group to study, to socialize, to make friends, and to learn from each other and the cultures of each one involved.

Search for a few career mentors for guidance. It will save us a lot of time while we are lost in a maze of professional nursing. In the United States, nursing opportunities are endless; we have a great many options for our advancement. It is not like when we thought nursing jobs were limited to a hospital or clinic.

Ask for help. Ask for input to clarify any confusion. We want to do it right the first time and we want to do the right thing. We have to triple-check all we do, because patient outcomes are in our hands.

Past personal beliefs like “Be quiet” and “Silence is a golden” – these don’t have much validity or value here. Not speaking up and not asking questions – these are not appropriate in this country. Do raise questions as appropriate.

Attachment I: Examples of possible solutions and preparation to bridge the differences in changing and adapting our professional nursing practice in the United States.

Differences

Our Possible Solutions

Assess and re-assess our patients

Review and review, and review again physical assessment books. Memorize them as much as possible and as needed.

Bring a handbook that we like such as “SkillMasters 3-Minute Assessment by Spring House 2006” to work for references.

Bring bilingual dictionary to work for references.

Practice American way as soon as we learn. Use it frequently.

Report abnormal finding

Use SBAR for all verbal and written communications. Write down talking points for our verbal communication also.

Use read-back method for all verbal orders.

Ask the caller to spell it out or slow it down as needed.

It is perfectly fine to state the obvious; let the speaker know that English is our second language.

Ask speaker to listen to us attentively. It takes time to get use to our accent. Remember, listening skills are very important in any conversation.

Be aware and tell our nurse managers that we did not have experience in these areas.

Take initiative to attend emergency-related classes in our hospitals as soon as we can and take as many classes as needed.

Increase our comfort level through self-study, group discussions and simulation labs. Find a preceptor or mentor to practice with us.

Giving P.O. medications and medication reconciliation

Take time to observe patients taking their medications every time before we move on to the next task.

Don’t put meds on the bedside table or on an over-bed table.

Learn to perform medication reconciliation as needed.

Protect patients’ privacy and protect colleagues’ privacies

Remember patient information is the patient’s private property. We need written permission from the patient, law and regulations, such as our facilities’ policies before we can share it.

Plan ahead and create a simple sentence such as “I am sorry that I do not have a permission to give that information.”

Attachment II - SBAR

The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team about a patient's condition. SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety.

Background

Michael Leonard, MD, Physician Leader for Patient Safety, along with colleagues Doug Bonacum and Suzanne Graham at Kaiser Permanente of Colorado (Evergreen, Colorado, USA) developed this technique. The SBAR technique has been implemented widely at health systems such as Kaiser Permanente.

Directions

This tool has two documents:

SBAR Guidelines (“Guidelines for Communicating with Physicians Using the SBAR Process”): Explains in detail how to implement the SBAR technique

SBAR Worksheet (“SBAR report to physician about a critical situation”): A worksheet/script that a provider can use to organize information in preparation for communicating with a physician about a critically ill patient

Both the worksheet and the guidelines use the physician team member as the example; however, they can be adapted for use with all other health professionals.

By SBAR Technique for Communication: A Situational Briefing Model

Page Content

Kaiser Permanente of Colorado Evergreen, Colorado, USA

Attachment III – Read-Back

Read-back is a way to verify of the complete order by the person who receiving the verbal order. The receiving person will repeat the verbal order back to the ordering clinician, who will verbally confirm that the repeated order is correct. The purpose of “Read-back” is to ensure patient safety.

The article is the collaborative work of a team of Chinese American Nurses (CAN) sisters. It speaks as “foreign” nurses who have worked in America for a number of years. Our group is very lucky to have CAN meetings twice a month. We have each other’s support. We share our setbacks and clarify our things that might confuse us. Together we provide opportunities to think things through; to have a better understanding of ourselves, to not let fear paralyze us; and to add strengths to face tomorrow with positive thoughts and energy. Go CAN!! Go!!!

Last month, a CAN nurse started to talk about the major differences that we are experiencing in the nursing functions and practices between China and the United States. Everyone joined in the discussion.

Assess and Reassess Our Patients

In USA:Nurses are expected to know as much as possible about our patients. Nurses have a major responsibility in the assessment and re-assessment of our patients. Most nurses are doing a great job in assessing patients. Nurses are at patients’ bedside 24x7. Physicians are not. We may notice a change first, and take action as the law allows. We can initiate many nursing protocols, especially in an emergency, and then we report the changes to physicians. Physicians come to assess, verify, confirm the changes, and take additional actions.

In China:The nurse-to-doctor ratio is nearly 1:1 in China. Doctors are just like nurses, at patients’ bedside 24x7. When new patients arrive, doctors perform the first assessments.

Report Abnormal Findings:

In USA:Nurses report abnormal findings from our own assessments or from the results we receive from other departments or facilities. Most of our current practice is to report the results to nurses first. Nurses are expected and required to report abnormal findings to physicians. We can take actions that are legally allowed. Many nursing protocols are there for us to utilize, especially in an emergency, and then we turn around and report the results to physicians. Physicians come to assess, verify, confirm the changes, and take additional actions.

In China:Doctors on the units get reports first. Nurses may not be aware of the results and reports. Therefore, nurses may not be aware of changes or actions needed.

Emergency Responsibilities:

In USA:Nurses or anyone who witnesses the need can call a code. A nurse is usually the initial emergency responder, until an organized team comes. Teams, including physicians, take over the emergency situation. Organized teams, such as the Rapid Response Team, Code Blue Team, and Trauma Team, have additional training in things like Advanced Critical Life Support and Pediatric Advanced Life Support.

In China:Doctors are at the patient’s bedside or nearby to respond and initiate emergency actions.

Administering Medications:

In USA:Nurses are responsible to ensure medications which are taken by mouth (P.O. medications) are swallowed every time, with no exceptions. In the Medication Reconciliation process in some facilities, nurses verify medications on an on-going basis. Verbal and telephone orders are seen often in some facilities.

In China:In past practice, P.O. medications might be left at the patient’s bedside or with their families, trusting that the patients would take their medications. This is not the right thing to do. It is very dangerous. What if a patient purposely hides his/her medications, and then overdoses on them? China’s nursing practice is changing; now nurses are watching patients take their medication more often. Doctors are there to verify medications in the Medication Reconciliation process. No verbal orders.

HIPAA Regulations:

In USA:A patient’s health information is very private, personal property. It totally belongs to the patient. If we don’t have a patient’s written consent, or regulatory permissions, then we cannot give personal information to anyone except the patient. Self-imposed “kindness” such as initiating family or community support for a patient without the patient’s permission is no long allowed. For example, let’s say we go to work at the hospital and see our neighbor who is very sick. Our sick neighbor needs help, especially with child care. We cannot tell another neighbor who we think would be happy to help with the sick neighbor’s child. We have to plan ahead, talk about our intent, and ask the sick neighbor’s permission before we talk to the helpful neighbor. We would be violating the sick neighbor’s confidentiality if we talk to another neighbor without the sick neighbor’s permission.

In China:Helpfulness and kindness are always welcome as long as it is a sincere act.

Sterile Technique

Performing and maintaining a sterile technique is a big deal in infection control to the nursing practice of both countries. Maintaining sterile technique saves lives, time and money.

In USA:In some cases, CAN nurses had the perception that a few of their nurse co-workers’ practices were a bit sloppy. When you notice the lack of sterile technique, you must speak up. Express concern about contamination. This is a time to educate our co-workers in a kind way. Often the nurses who are doing the job may not be aware that contamination has occurred. Mentally, we know that it is difficult for us to point out any possible contaminations or any wrong doing. Culturally we were taught to pretend that we did not see; let others do whatever they want to do; we do what we are supposed to do to keep ourselves clean. “Mind our own business,” is what we learned. But in today’s world we need to prepare a simple and easy phrase or sentence that will help us to gently point out possible contamination. It will save lives. We have a lot to learn about how to be assertive and to be an advocate for our patients.

In China:The fear of contamination and the strict self-monitoring of sterile techniques are emphasized more. CAN sisters feel that because of our past strict training, sterile technique is branded into our minds.

PIV Insertions:

In USA:Many facilities prefer to have IV Teams for Peripheral IV insertions to save nursing time, promote patient satisfaction, and decrease line infections. Therefore, nurses’ experiences in starting PIVs are very different. Some nurses do not have to start an IV at all and they have no skill in PIV insertion. For some nurses who start PIVs occasionally, their skill is hit-and-miss. Very few nurses are good at PIV insertion.

In China:CAN nurses discovered in the support group meeting that most of nurses are good at PIV insertions. We found out that CAN nurses are the “go-to person” for performing PIV insertions. Personally, I have never paid much attention to this as a big difference. It was delightful to find out that this is one of our common strengths.

Salaries & Bonuses:

In USA:We make good salaries as nurses, even after about 40% is withheld in taxes, income taxes, and sale taxes. On the other hand, if we compare our salaries to physicians’ salaries, we find out a real gap. Physician pay is much higher. Of course, there are good reasons. Physician education and training are much longer and more in depth, and more physically and emotional demanding than nurses’ education. The demand for physicians is greater than the supply of physicians. We have many physician assistants and nurse practitioners who work under physicians and support some of our physician functions and responsibilities.

In China:Nurses and physicians both have two types of incomes – regular salary and bonus. The nurses’ salaries are much closer to physicians’ salaries in China. Chinese doctors and nurses are equally compensated by the government. It is a perfect system for equal professionals. The differences in their earnings come from their bonuses, which are regulated and paid by the hospital. Currently, no nurse practitioners are working in a hospital or clinic in China.

Nurse to Physician Ratio:

In USA:The variety of job choices for nurses is huge, including acute hospital care, clinics, nursing homes, home health, insurance, occupational health, schools, law firms, etc. The nursing functions and responsibilities are varied, and it is very different in different health-care and non-health care settings. The physician to nurse ratio ranges from 1:4 to 1:8 or more, depending on the type of facility and the time of day or night. Some nurses function independently.

In China:Most of nurses are working in hospitals and clinics, the nurse to physician ratio is nearly 1:1. It is a perfect ratio for an equal professionalism. No nurses are function independently.

For us “foreign” nurses, especially those of us who have studied nursing or grown-up abroad, we often find that nursing functions and practices are very similar in some ways and quite different in other ways. This becomes apparent particularly on initial entry into the nursing profession in the USA. Adaptation will ease most barriers. The sooner we can identify the differences, analyze them, and find ways to adjust, the sooner we will adapt to the United States’ way of practice. As we open our hearts and minds to learn new things, we can expand our horizons. Every challenge forces us to learn and to bring out undiscovered talents within us, thereby making us stronger. There is no failure in trying to do the best we can do; the only failure is not trying to change and adapt to a different way of doing things. There are times we have to be brave enough, to have enough self confidence, and to excel on own strengths. We want to keep very strong, solid nursing skills, such as peripheral IV insertion skills. We want to keep the valuable nursing concepts, such as sterile techniques with us. Our skills will be lost if we do not practice constantly. In all, we are excited that we have opportunities to brand ourselves as the best we can be in United States.